CLARITY HMIS: HHS-­RHY PROJECT EXIT FORM

Use block letters for text and bubble in the appropriate circles.

Please complete a separate form for each household member.

CLIENT NAME OR IDENTIFIER:______

PROJECT EXIT DATE​​[All Clients]

­ / ­

Month Day Year

CLIENT LOCATION [only if multiple CoC’s] ______

DESTINATION[­All Clients]

○ / Deceased / ○ / Rental by client, with RRH or equivalent subsidy
○ / Emergency shelter, including hotel or motel paid for with emergency shelter voucher / ○ / Rental by client, with VASH housing subsidy
○ / Foster care home or foster care group home / ○ / Rental by client, with GPD TIP housing subsidy
○ / Hospital or other residential non­-psychiatric medical facility / ○ / Rental by client, with other ongoing housing subsidy
○ / Hotel or motel paid for without emergency shelter voucher / ○ / Residential project or halfway house with no homeless criteria
○ / Jail, prison or juvenile detention facility / ○ / Safe Haven
○ / Long-term care facility or nursing home / ○ / Staying or living with family, permanent tenure
○ / Moved from one HOPWA funded project to HOPWA PH / ○ / Staying or living with family, temporary tenure (e.g., room, apartment or house)
○ / Moved from one HOPWA funded project to HOPWA TH / ○ / Staying or living with friends, permanent tenure
○ / Owned by client, noongoing housing subsidy / ○ / Staying or living with friends, temporary tenure (e.g., room, apartment or house)
○ / Owned by client, with ongoing housing subsidy / ○ / Substance abuse treatment facility or detox center
○ / Permanent housing (other than RRH) for formerly
homeless persons / ○ / Transitional housing for homeless persons (including homeless youth)
○ / Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/airport or anywhere outside) / ○ / Other (specify):
○ / No exit interview completed
○ / Psychiatric hospital or other psychiatric facility / ○ / Client doesn’t know
○ / Client refused
○ / Rental by client, no ongoing housing subsidy / ○ / Data not collected

PROJECT COMPLETION STATUS ​[Head of Household, Adults, and Unaccompanied youth]

○ / Completed project / ○ / Youth was expelled or otherwise involuntarily discharged from project
○ / Youth voluntarily left early
If youth was expelled or otherwise involuntarily discharged – Major reason
○ / Criminal activity/destruction of property/violence / ○ / Reached max times allowed by project
○ / Non­compliance with project rules / ○ / Project terminated
○ / Non­payment of rent/occupancy charge / ○ / Unknown/disappeared

DISABLING CONDITION ​[All Clients if ‘yes’ to any condition, mark ‘yes’

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

PHYSICAL DISABILITY ​[All Clients]

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
IF “YES” TO PHYSICAL DISABILITY – SPECIFY
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? / ○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

DEVELOPMENTAL DISABILITY ​[All Clients]

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
IF “YES” TO DEVELOPMENTAL DISABILITY – SPECIFY
Expected to substantially impair ability to live independently? / ○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

CHRONIC HEALTH CONDITION ​[All Clients]

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
IF “YES” TO CHRONIC HEALTH CONDITION – SPECIFY
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? / ○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

HIV-AIDS ​[All Clients]

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
IF “YES” TO HIV-AIDS – SPECIFY
Expected to substantially impair ability to live independently? / ○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

MENTAL HEALTH PROBLEM ​[All Clients]

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
IF “YES” TO MENTAL HEALTH PROBLEMS – SPECIFY
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? / ○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

SUBSTANCE ABUSE PROBLEM ​[All Clients]

○ / No / ○ / Both alcohol & drug abuse
○ / Alcohol abuse / ○ / Client doesn’t know
○ / Client refused
○ / Drug abuse / ○ / Data not collected
IF “ALCOHOL ABUSE” “DRUG ABUSE” OR “BOTH ALCOHOL AND DRUG ABUSE”– SPECIFY
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? / ○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

INCOME FROM ANY SOURCE ​[Head of Household and Adults]

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
IF “YES” TO INCOME FROM ANY SOURCE – INDICATE ALL SOURCES THAT APPLY
Income Source / Amount / Income Source / Amount
○ / Alimony and Other Spousal Support / ○ / Child support
○ / Pension or Retirement income from former job / ○ / Earned Income
○ / Retirement Income from Social Security / ○ / General Assistance (GA)
○ / Social Security Disability Insurance (SSDI) / ○ / Private Disability Insurance
○ / Supplemental Security Income (SSI) / ○ / Unemployment Insurance
○ / TANF (Temporary Assist for Needy Families) / ○ / Worker’s Compensation
○ / VA Service Connected Disability Compensation / ○ / Other source
○ / VA Non-­Service Connected Disability Pension / Other (specify):
Total monthly amount:

RECEIVING NON­CASH BENEFITS​​[Head of Household and Adults]

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
IF “YES” TO NON­CASH BENEFITS – INDICATE ALL SOURCES THAT APPLY
○ / Supplemental Nutrition Assistance Program (SNAP) / ○ / TANF Childcare Services
○ / Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) / ○ / TANF Transportation Services
○ / Other (Specify): / ○ / Other TANF-funded services

COVERED BY HEALTH INSURANCE ​[All Clients]

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
IF “YES” TO HEALTH INSURANCE ­ HEALTH INSURANCE COVERAGE DETAILS
○ / MEDICAID / ○ / Employer Provided Health Insurance
○ / MEDICARE / ○ / Insurance Obtained through COBRA
○ / State Children’s Health Insurance (SCHIP) / ○ / Private Pay Health Insurance
○ / Veteran’s Administration (VA) Medical Services / ○ / State Health Insurance for Adults
○ / Other (specify) / ○ / Indian Health Services Program

RHY SPECIFIC YOUTH INFORMATION

LAST GRADE COMPLETED ​[Head of Household, Adults and unaccompanied Youth]

○ / Less than Grade 5 / ○ / Grades 5-6
○ / Grades 7-8 / ○ / Grades 9-11
○ / Grade 12 / ○ / School does not have grade levels
○ / GED / ○ / Some college
○ / Associate’s Degree / ○ / Bachelor's degree
○ / Graduate Degree / ○ / Vocational certification
○ / Client doesn't know
○ / Data not collected / ○ / Client refused

SCHOOL STATUS ​[Head of Household, Adults, and unaccompanied Youth]

○ / Attending school regularly / ○ / Suspended
○ / Attending school irregularly / ○ / Expelled
○ / Graduated from high school / ○ / Client doesn’t know
○ / Obtained GED / ○ / Client refused
○ / Dropped out / ○ / Data not collected

EMPLOYMENT STATUS ​[Head of Household, Adults, and unaccompanied Youth]

Employed
○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
If “Yes” for employed – Type of employment
○ / Full­time / ○ / Seasonal/sporadic (including day labor)
○ / Part-time
If “No” for employed – Why not employed
○ / Looking for work / ○ / Not looking for work
○ / Unable to work

GENERAL HEALTH STATUS ​[Head of Household, Adults, and unaccompanied Youth]

○ / Excellent / ○ / Poor
○ / Very good / ○ / Client doesn’t know
○ / Good / ○ / Client refused
○ / Fair / ○ / Data not collected

DENTAL HEALTH STATUS ​[Head of Household, Adults, and unaccompanied Youth]

○ / Excellent / ○ / Poor
○ / Very good / ○ / Client doesn’t know
○ / Good / ○ / Client refused
○ / Fair / ○ / Data not collected

MENTAL HEALTH STATUS ​[Head of Household, Adults, and unaccompanied Youth]

○ / Excellent / ○ / Poor
○ / Very good / ○ / Client doesn’t know
○ / Good / ○ / Client refused
○ / Fair / ○ / Data not collected

PREGNANCY STATUS ​[All Female Head of Household, Adults, and Unaccompanied Youth]

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
If “Yes” for Pregnancy Status
Due Date:

COMMERCIAL SEXUAL Exploitation/Sex TRAFFICKING

Ever received anything in exchange for sex (e.g. money, food, drugs, shelter)?

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
IF “YES”
In the last three months? / ○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

How many times (ever)?

○ / 1-3 / ○ / Client doesn’t know
○ / 4-7 / ○ / Client refused
○ / 8-11 / ○ / Data not collected
○ / 12 or more

Ever made/persuaded/forced to have sex in exchange for something?

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
IF “YES”
In the last three months? / ○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

LABOR EXPLOITATION /TRAFFICKING

Ever afraid to quit/leave work due to threats of violence to yourself, family, or friends?

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

Ever promised work where work or payment was different than you expected?

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

If “YES” Felt forced, coerced, pressured or tricked into continuing the job?

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected
IF “YES”
In the last three months? / ○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

COUNSELING

Counseling received by client?

○ / No
○ / Yes

IDENTIFY the TYPE(s) of COUNSELING RECEIVED

○ / Individual / ○ / Group - including peer counseling
○ / Family

Identify the number of sessions received by exit ______

SAFE and APPROPRIATE EXIT

Exit destination safe – as determined by the client

○ / No / ○ / Client doesn’t know
○ / Yes / ○ / Client refused
○ / Data not collected

Exit destination safe – as determined by the project/caseworker

○ / No / ○ / Worker Doesn’t Know
○ / Yes

Client has permanent positive adult connections outside of project?

○ / No / ○ / Worker Doesn’t Know
○ / Yes

Client has permanent positive peer connections outside of project

○ / No / ○ / Worker Doesn’t Know
○ / Yes

Client has permanent positive community connections outside of project

○ / No / ○ / Worker Doesn’t Know
○ / Yes

CONTACT INFORMATION [Optional- can be entered in Location Tab]

Phone Number / ­ / ­
Email
Current Address (if applicable)
Street
City
State / Zip Code

Signature of applicant stating all information is true and correct Date